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Abdomen Radiography. Abdomen Module. Sean Duguay and Justin North, MD. Directions. View in presentation mode This module is meant for independent study Highlighted words in yellow have actions Clicking on them once will identify certain areas
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Abdomen Radiography Abdomen Module Sean Duguay and Justin North, MD
Directions • View in presentation mode • This module is meant for independent study • Highlighted words in yellow have actions • Clicking on them once will identify certain areas • Clicking on them again will remove identifiers • This icon is present when there is additional information in the note section
Objectives • Recognize normal anatomic structures • Systematic search pattern • Recognize pathology: obstruction, free air, mass, infection/inflammation, stones • Ordering abdomen imaging - Algorithms • Adult vs. Pediatric imaging
Normal Anatomy Upright Abdomen Heart CT Coronal Lungs Diaphragm Stomach Liver Gallbladder Pancreas Small Intestine Ascending Colon Transverse Colon Descending Colon
Normal Anatomy Upright Abdomen CT Coronal Spleen Psoas Muscles Vertebral Column Aorta Inferior Vena Cava Abdomen Wall Ribs – Anterior Ribs – Posterior Kidneys
1 Search Pattern Common Groupings • Bones • Stones • Gas • Mass Midline LUQ RUQ LLQ RLQ Quadrants • RUQ • RLQ • LUQ • LLQ • Midline Midline
Search Pattern Bones • Evaluate ribs, spine, pelvis and femurs for fracture, dislocation, subluxation, osteoarthritic changes, and lesions • Evaluate soft tissues for subcutaneous air, foreign bodies, and surgical clips
Search Pattern Stones • Evaluate kidneys, ureters, bladder, and urethra for opacities • Evaluate deposition of calcium in… • Arteries: aorta, iliac, renal • Organs: GB, appendix • General regions: Pelvis *Phlebolith = calcified pelvic veins commonly mistaken for urinary tract stones
Search Pattern Gas • Evaluate intraluminal air within stomach, GB, small intestine, large intestine, and rectum for dilatation, air-fluid levels, and bowel orientation • Evaluate extraluminal airunder diaphragm or between bowel for perforation • Evaluate periphery for subcutaneous air
Search Pattern Mass • Evaluate for organomegaly • Bladder • Spleen • Liver • Kidneys • Mass effect • Shadows • Psoas • Abdomen Wall
Search Pattern RUQ: Liver, GB, hepatic flexure, kidney, ureter RLQ: Appendix, cecum, ureter, ovary, psoas m. LUQ: Pancreas, spleen, splenic flexure, kidney, ureter, stomach, diverticulum LLQ: Diverticulum, ureter, ovary, psoas m. Midline: Spine, aorta, IVC, uterus All: Small intestine Midline LUQ RUQ LLQ RLQ Midline
Case 1 • 78 yo female with h/o fall c/o bilateral hip pain • Findings: • Diagnosis: - Bilateral femur fractures • Bilateral femoral cortical • defects
1 Case 2 • 39 yo male with h/o left colicky pain radiating towards groin and gross hematuria • Findings: • Diagnosis: - Nephrocalcinosis • Opacification in left kidney • region
1 Case 3 • 58 yo male with h/o alcoholism complains of chronic epigastric pain, occasionally radiating to back • Findings: • Diagnosis: - Chronic Pancreatitis • Punctate calcifications along • distribution of pancreas
Case 4 • 49 yo overweight female with h/o chronic colicky RUQ pain after meals • Findings: • Diagnosis: • - Porcelain GB likely secondary to chronic cholecystitis • - Calcification of GB wall
1 Case 5 • 67 yo with h/o diffuse abdomen pain suddenly c/o right shoulder pain • Findings: • Diagnosis: - Ruptured abdominal viscus • - Air under right diaphragm • (pneumoperitoneum) Rigler’s Sign (Double Wall Sign) • - Rigler’s sign • - Safety pin likely on gown Upright Plain Film
1 Case 5 (Cont…) • Which air is the free air? • - Free Air • - Not Free Air
1 Case 6 • 54 yo with h/o laparotomy at age 37 for acute appendicitis develops increasingly severe abdomen pain • Findings: • Diagnosis: - Small bowel obstruction likely secondary to adhesions • Should see air in this distribution • Plicae circulares • Dilated small bowel • - Dilated loops of small bowel with visible plicae circulares • - Lack of large bowel dilation • 3,6,9 Rule (Normals) • Small Bowel < 3 cm • Large Bowel < 6 cm • Cecum < 9 cm
1 Case 7 • 78 yo with h/o sudden left lower quadrant pain • Findings: • Diagnosis: - Sigmoid Volvulus • “Bent inner tube” • Or • “Coffee Bean Sign” • - Loop of dilated bowel pointing cranially • - Lack of air in rectum
1 Case 8 • 64 yo male c/o hemochezia, constipation, and weight loss for 6 mo • Findings: • Diagnosis: - Colon Cancer • - Descending colon filling defect “Apple core” lesion Double Contrast Barium Enema
1 Case 9 • 59 yo male with h/o alcoholism, weight loss, nausea and vomiting develops abdomen distension over last two years • Findings: • Diagnosis: • - Alcoholic hepatitis (from biopsy) • - Hepatomegaly • - Stool due to constipation • (enhanced 2o oral contrast)
1 Case 10 • 51 yo female with h/o IV drug use develops abdomen distension and spider angiomata • Findings: • Diagnosis: - Viral Hepatitis (from biopsy) • - Ascites
1 Case 11 • 17 yo female with h/o elevated bhcg and left flank pain • Findings: • Diagnosis: • Pregnancy • Post-renal failure 2o obstruction w/ stent placement • - Fetus • - Ureter stent Head Spine
Case 12 • 22 yo male with h/o RLQ pain for last twelve hours and fever • Findings: • Diagnosis: - Appendicitis • - Inflammatory changes around appendix • (fat stranding)
Case 13 • 69 yo with h/o constipation and occasional hematochezia c/o severe LLQ pain • Findings: • Diagnosis: - Diverticulitis • - Diverticula • - Inflammatory changes around colon diverticulum • (fat stranding)
Case 14 • 45 yo female with h/o recurrent kidney stones and urinary tract infections • Findings: • Diagnosis: • - Kidneys joined at midline • - Horseshoe kidney
Case 15 • 35 yo male with h/o cerebral aneurysm • Findings: • Diagnosis: • - Bilateral enlarged kidneys with multiple cysts • - Multiple hepatic cysts • - Polycystic Kidney Disease
Case 16 • 45 yo female with history of generalized abdomen pain • Findings: • Diagnosis: • Normal Adrenal Gland • Mass • Bilateral adrenal mass • Normal adrenal gland • No other acute findings • Adrenal adenoma • (most commonly identified incidentally and not clinically significant)
Case 17 • 18 month child with h/o painless rectal bleeding and intussusception • Findings: • Diagnosis: • Increased uptake right lower • quadrant (likely ileum) • Increased uptake in • stomach and bladder • - Meckel’s diverticulum Technetium-99m (99mTc) pertechnetate scan
Case 18 • Newborn male with failure to pass meconium w/in 48 hrs • Findings: • Diagnosis: • Dilated colon • No air in rectum or distal colon • - Hirschsprung’s Disease
Case 19 • Newborn female with h/o polyhydramnios and bilious vomiting • Findings: • Diagnosis: • Dilated stomach and proximal duodenum • - Absence of air beyond proximal duodenum • - Duodenal atresia • “Double bubble” sign
Case 20 • 33 yo female with h/o ulcerative colitis, jaundice, and fatigue • Findings: • Diagnosis: • Multiple intrahepatic • biliary strictures • Multiple space-occupying • defects (likely air or stones) • Primary sclerosing • cholangitis ERCP of biliary tree
Case 21 • 49 yo male with h/o right costophrenic tenderness and dysuria • Findings: • Diagnosis: • - Irregular hyperdensity in distribution of right kidney • - Staghorn calculus
Case 22 • 35 yo female with h/o smoking and oral contraceptive use • Findings: • Diagnosis: • Wedge-shaped perfusion • defect reaching periphery • - Splenic infarction
Intrauterine Device (IUD) • Fundus of uterine cavity • in T configuration • Indications • Contraception, emergency contraception, reduce heavy bleeding • Positioning • Malposition • Partially expelled • Malrotation • Migration
Ureter Stent • Stent positioned from renal • pelvis to bladder (coil seen in • both locations) • Indications • Ureteral obstruction, prophylactic, newly created ureteral anastamoses • Positioning • Complications seen on x-ray • Migration out of kidney or bladder • Stent calcification
IVC Filter • Inferior Vena Cava (above or • below renal veins depending on • VTE origin) • Indications • Contraindications to anticoagulation, VTE (venous thromboembolism) refractory to anticoagulation • Positioning • Complications seen on x-ray • Migration • Fragmentation
Endograft • Abdominal aorta +/- common • iliac arteries • Indications • Abdominal aortic or aorto-iliac aneurysms • Positioning • Complications seen on x-ray • Migration • Kinking • Fragmentation
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